Siribha Changsirikulchai
HRH Princess Maha Chakri Sirindhorn Medical Center (MSMC)
Renal Division, Department of Medicine
Faculty of Medicine, Srinakharinwirot University
The 4Rs of Peritonitis:
Recurrent, Relapsing
Repeat and Refractory
21st July, 2019
Scope of contents
Definition, microbiology and outcomes in 4Rs
(recurrent, relapse, repeat, and refractory PN)
Treatment and prevention to reduce peritonitis
(PN) episodes
Information of PN from Thai PD First
Definitions of Recurrent, Relapsing, Repeat, Refractory
Terms Time Organism
Recurrent occur less than 4 weeks after end of complete treatmentof previous episode
different organism from previous episode
Relapse occur less than 4 weeks after end of complete treatmentof previous episode
same organism or witha negative culture
Repeat occur more than 4 weeks after end of completetreatment of previous episode
same organism from previous episode
Refractory failure of effluent to clear after 5 days of appropriateantibiotics
Different clinical implication between
relapse and recurrent peritonitis
PD patients with relapsing PN
- develop antibiotic resistance during treatment resulting in a different antibiotic susceptibility pattern
- source of relapse: catheter through either biofilm or tunnel
infection
- consider catheter removal
PD patients with recurrent PN
- impaired immunity by first episode, leading to episode of PN
from a completely different organism, implying a different cause
- treated successfully without catheter removal
Am J Kidney Dis 2009; 54: 702-10
Am J Kidney Dis 2011; 58: 429-36
Am J Kidney Dis 2009; 54: 702-10
Am J Kidney Dis 2011; 58: 429-36
Am J Kidney Dis 2012, 59: 84-91
Clin J Am Soc Nephrol 2011; 6:827-33
PDI 2012;32: 316-21
Study in Canadian PD patients to determine microbiology of PN
with multiple PN episodes
Exclude relapsing or recurrent PN and PN episodes occurring
within 60 days of previous episodes = select repeated and non-
repeated PN
Most common organisms
causing repeated PN: CNS
Having a first episode of CNS
PN associated with an increased
risk of subsequent CNS PN
within 1 year of the earlier
episode
Management of Peritonitis
After initiate appropriate antibiotic, clinical PN should improve in 72 hours
Failure of PD effluent to clear up after 5 days of appropriate antibiotics, catheter removal is indicated
To avoid extended hospital stay, peritoneal membrane damage, increased risk of fungal PN, and excessive mortality: other indications for catheter removal
- Relapsing peritonitis
- Refractory exit-site and tunnel infection
- Fungal peritonitis
- Catheter removal may also be considered for: repeated PN
mycobacterial PN, multiple enteric organismsISPD Peritonitis recommendations: 2016 Update on prevention and treatment
Simultaneous catheter replacement and removal for treatment of peritonitis
Other adjunctive treatment of Peritonitis
Intraperitoneal urokinase:
- a retrospective study found that IP urokinase with oral
rifampicin, in addition to conventional antibiotics, resulting
in catheter salvage 64% of patients with CoNS infection
(PDI 2009; 29:548-53)
- RCT studies failed to show benefit of IP urokinase for
treatment of refractory PN (J Nephrol 2005; 18:204)
(Adv Perit Dial 2000; 16: 233) (NDT 1994; 9: 797)
- A RCT study showed that simultaneous catheter removal
and replacement superior to IP urokinase in reducing
relapsing PN episodes
Antibiotic lock on Tenckhoff catheter
Report cases with relapsing PN (due to culture negative,
E.coli and Pseudomonas spp)
Promising results
Issues need to address before using antibiotic lock
- prolonged dwell
- consider antibiotic lock if PN well controlled by IP antibiotic
- timely removal of Tenckhoff catheter when PN not respond
to IP antibiotic therapy
- uncertain appropriate regimen of antibiotic lock in duration
and frequency
Other adjunctive treatment of Peritonitis
1. Adv Perit Dial 1992;8:302-5 2. PDI 2017;37: 475 3. PDI 2019; 39:187
Risk factors of peritonitis
Social and environmental factors such as pets, poor hygiene
Medical factors: - Obesity
- Depression
- Hypokalemia
- Hypoalbuminemia
- Invasive interventions
- Comorbidity affect to change in dexterity
- Bowel and gynecological source of infections
Dialysis-related: - Training
- Wet contamination
Infection-related: - nasal S.aureus carrier status
- previous ESI
Modified from ISPD Peritonitis recommendations: 2016 Update on prevention and treatment
PDI 2018;38:251
To evaluate effect of economic deprivation on PN episodes
Most deprived educational group experienced ≥ 2 PN episodes
and higher rates of hospitalization than least deprived group
To investigate whether cognitive impairment contributed to
risk of PD-related PN
Immediate memory dysfunction was independently associated
with a higher risk of PD-related PN
Perit Dial Int 2019; 39: 229
Contribution of biofilm to pathogenesis of PD infections
To evaluate etiology of biofims on PD catheters
Study in 47 patients whom catheter was removed due to
infecious and non-infectious causes
Results: - Staphylococci (CNS and Staphylococcus aureus)
and P.aeruginosa predominant species
32% and 20% in infection group
43.3% and 22.7% in non-infection group
- Colonization level in cuffs higher in catheter removed due to
infectious vs. non-infectious causes
- Median microbial yield higher in cuffs than in silicone segment
in both infectious and non-infectious groups
Sampaio J. Plos One 2016; 23: 1-15
How to reduce peritonitis and 4Rs
Plan, Do, Check, ActCQI Process
Continuous quality improvement process
Monitor incidence of PN rate: define goals
Root cause analysis: determine etiology, risk factors of PN
Design solutions: intervention direct against reversible
etiology, risk factors to prevent another episodes of PN
RCA to determine risk of peritonitis
Contamination:
- coagulase-negative Staphylococcal species usually
associated with touch contamination
Transmural migration of enteric organism:
- constipation, diarrhea, endoscopic or gynecological
procedures
Bacteremia: after dental procedures
Biofilm: relapsing CoNS peritonitis
Processes of care to prevent PD-related PN
Systemic prophylactic antibiotics before catheter insertion
Topical antibiotics cream (mupirocin or gentamicin) apply at
catheter exit site
Prompt treatment of exit site or catheter tunnel infection
Antibiotic prophylaxis prior to invasive procedures
Antibiotic prophylaxis after wet contamination
Regular check and treatment of S.aureus nasal carriers
Home visit to detect problems with exchange technique,
adherence to protocols, environmental and behavior issues
Retraining in steps of PD exchange procedure
ISPD Peritonitis recommendations: 2016 Update on prevention and treatment
Indications for PD Re-training
Following prolonged hospitalization
Following peritonitis and/or catheter infection
Following change in dexterity, vision, or mental
acuity
Following change to another supplier or a different
type of connection
Following other interruption in PD (e.g. period of
time on hemodialysis)
ISPD Peritonitis recommendations: 2016 Update on prevention and treatment
https://dpex.thaicarecloud.org
Analysis of patients on CAPD with peritonitis
registered in DPEX during 2008-2018
Patients Number (case) Percent
Patients without PN 15,121 69.1
Patients with 1 episode of PN
3,825 17.5
Patients with > 1 episodeof PN
2,939 13.4
21,885 CAPD patients registered in DPEX
(92 centers from 253 centers = 36.4%)
Unpublished data from Database of Peritoneal dialysis in EXcel (DPEX)
Characteristics among patients without PN, with 1 episode, and with >1 episodes of PN
Outcomes among patients without PN, PN with 1 episode, and with >1 episodes of PN
Unpublished data from Database of Peritoneal dialysis in EXcel (DPEX)
Patterns of multiple episodes of PN in PD patients registered in DPEX during 2008-2018
2,266 PN episodes in PD patients with multiple episodes of PN and having data of organism
Category of multiple PN Episode %
Recurrent PN 150 6.6
Relapsing PN 250 11.0
Repeated PN 997 44.0
Multiple episodes of PN occurred after 4 weeks and culture no growth (non-repeated)
869 38.4
Unpublished data from Database of Peritoneal dialysis in EXcel (DPEX)
Types of microbiology in multiple episodes of PN
Unpublished data from Database of Peritoneal dialysis in EXcel (DPEX) ** **
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Abstract submission to APCM- ISPD Nagoya 2019 Objective: Fight to improve PDE culture no growth
Abstract submission to APCM- ISPD Nagoya 2019 Objective: Fight to improve PDE culture no growth
Call Me Please: to prevent gram negative
Peritonitis in CAPD patients with diarrhea
Presentation in Hospital Accreditation Forum 2016
Group education, train hand washing, call to PD nurse
- Focus in hand washing
- Prescribe 2 days of oral
antibiotics
Patients with peritonitis and history of diarrhea Number
1. Number of PD patients with diarrhea 20
1.1 No peritonitis (%) 12 (60%)
1.2 Develop peritonitis (%) 8 (40%)
2. Number of PD patients with diarrhea receive training 11
2.1 No peritonitis (%) 8 (72.8%)
2.2 Develop peritonitis (%) 3 (27.3%)
3. Number of PD patients with diarrhea, no training, no PN
4
Results of CQI: Call Me Please
Poster presented at PD Forum – 2018Fight to improve gram positive PNfrom touch contamination
Minitest for dexterity is a KPI (process) which has to
be performed once a year in every patients on CAPD
Poster presented at PD Forum - 2018
A 72 year old male on CAPD with multiple episode of PN
What was the cause of multiple episodes of PN?
Conclusions:
Gram positive microbials especially Staphylococcus
spp were common organisms found in repeated PN
Gram negative microbials and fungal peritonitis were
common organisms found in recurrent PN
Culture no growth were frequently found in relapsing
PN and non-repeated PN (Thailand)
Catheter removal should be performed in refractory
PN including fungal PN
Each PD units should monitor and perform CQI
process to reduce rates of PN
THANK YOU FOR YOUR ATTENTION
